1. U.S. Department of Energy 2016 ASP Workshop
DOECAP Phased Audits
U.S. Department of Energy ASP Workshop
George E. Detsis
Analytical Services Program Manager Office of Sustainable Environmental Stewardship
Office of Environment, Health, Safety and Security
U.S. Department of Energy
Covington, Kentucky September 19–22, 2016

2. Topics
Phased Audit Process
Path Forward Recommendations

3. New DOECAP Phased Audit Process
Purpose / Goal:
Voluntary participation on the part of the contracted Lab/TSDF
Incentivize and reward good performance
Embedding DOECAP requirements and audit checklist lines of inquiry into daily operations

4. Phased Audits: Phase I – Year 1
Lab/TSDF thoroughly fills out the DOECAP audit checklists and submits for review by the audit team prior to the on-site audit
Lab/TSDF assesses itself against the lines of inquiry in the audit checklists, self-identifies findings, and develops meaningful Corrective Actions (i.e., the Corrective Actions address the root cause and extent of condition for each finding)
DOECAP conducts full, on-site audit
DOECAP issues audit report
DOECAP reviews/tracks CAPs

5. Phased Audits: Phase II – Year 2
DOECAP conducts a limited scope, on-site audit (smaller audit team) contingent on implementation of self-identified findings and CAPs and utilizing the checklists. (Otherwise a full-scope audit will be conducted.)
Lab/TSDF updates the DOECAP checklists and submits for review prior to on-site audit
Lab/TSDF assesses itself against the lines of inquiry in the audit checklists, self-identifies findings, and develops meaningful Corrective Actions (i.e., the Corrective Actions address the root cause and extent of condition for each finding)
DOECAP issues audit report
DOECAP reviews/tracks CAPs

6. Phased Audits: Phase III – Years 3 and 4
DOECAP conducts a desktop audit (not on-site audit).
Lab/TSDF updates the DOECAP checklists and submits for review.
Lab/TSDF assesses itself against the lines of inquiry in the audit checklists, self-identifies findings, and develops meaningful Corrective Actions (i.e., the Corrective Actions address the root cause and extent of condition for each finding).
DOECAP issues audit report.
DOECAP reviews/tracks CAPs.
Year 4:
Contingent on performance, repeat the cycle of conducting full on-site audit, or limited on-site audit.

7. What is “Good Performance?”
DOECAP considers good performance to include a robust self-assessment program and CAP for internal and external findings.
Lab/TSDF incorporates the DOECAP audit checklist lines of inquiry into its daily operational activities.
Lab/TSDF implements meaningful corrective actions that address the root cause(s), extent of conditions, and the effectiveness of closure actions.
Did I get an “A” on checklists?

8. Status of Phased Audits FY 2016
Labs:
2016 is the first year of the Phased Audit Process for Labs.
Two Labs have volunteered for Phase I audits.
TSDFs:
Four TSDFs received Phase I audits.
One TSDF received a Phase II limited-scope audit.
One TSDF received a Phase III desktop audit.

9. Path Forward Recommendations
What have we learned from the Phased Audit Process?
Phase III audits do not work well for auditors.
DOECAP auditors cannot complete disciplined reviews in a comprehensive, timely manner because full-time job takes precedence over the audit.
While performing on-site audits, the DOECAP auditors can dedicate 100% of their time to the audit.

10. Path Forward Recommendations
Recommendations for Phase III audits:
DOECAP-audited Labs/TSDFs continue to complete all checklists and forward them to DOECAP Operations Team (not the DOECAP auditors).
DOECAP audited Labs/TSDFs submit internal and external findings and CAPs and forward them to DOECAP Operations Team.
DOECAP Operations Team produces a draft two-page memorandum for ASP Manager’s signature.
Final memo forwarded to Lab/TSDF.
Focuses on quality of the completed checklists and the tracking of findings and CAPs.

11. DOECAP Points of Contact
Labs—Joe Pardue
Technical Operations Coordinator
(865)
TSDF—Susan Aderholdt
Corrective Actions Coordinator
(865)
George E. Detsis
ASP Manager
(301)

12. Questions?